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The most difficult question I am asked by my patients is, "Why?" Why did I become an addict? Why do I still have cravings? Why do I slip up and use, even thought I know it's wrong and I feel stupid and horrible doing it? Despite all my knowledge, education and experience, my answer essentially is, "Because."

A Doctor's Struggle to Answer the Question: "Why Do I Like Drugs?"

The paper rustled and bunched up here, there, and everywhere as I rolled him from one end of the table to the other. Finally I said, "I need to do a rectal exam." He shot up straight, and yelped, "A what?"

My Malpractice Lawyer and Me

 that shifts the focus from the volume of services provided to the quality of care delivered. This paradigm shift aims to improve patient outcomes, reduce costs, and enhance the overall efficiency of the health care system. 

, as one of the largest health care payers in the United States, has played a pivotal role in implementing VBC initiatives.

One of the key advantages of VBC for Medicare is its potential to reduce health care costs. By 

 to deliver high-quality care efficiently, VBC can help curb unnecessary procedures, hospitalizations, and other costly medical interventions. This can lead to significant savings.

Another important benefit of VBC is its emphasis on improving patient outcomes. By focusing on quality rather than quantity, VBC encourages providers to deliver personalized care that addresses the specific needs of each patient. This can create positive health outcomes, increased patient satisfaction, and reduced readmission rates.

Medicare has implemented various VBC programs, including 

 (ACOs), bundled payments, and Comprehensive Primary Care Plus (CPC+) models. ACOs have gained significant traction as they bring together providers and hospitals to coordinate care and share in the financial risks and rewards.

While VBC has shown promising results, challenges remain. Implementing VBC requires a significant cultural shift within the health care industry, as it necessitates a move away from fee-for-service models. Additionally, there are concerns about the potential for disparities in care quality among different patient populations.

Value-based care represents a significant step forward in transforming the Medicare program. It has the potential to deliver substantial benefits to both beneficiaries and the health care system. As Medicare continues to expand and refine its VBC initiatives, it is crucial to address the challenges and capitalize on the opportunities to create a more sustainable and patient-centered health care system. To learn more, look at this slideshow created from an Aledade infographic.

Ahmed Haque leads Network Performance & Strategy at

, overseeing performance and shared savings across Accountable Care Organizations. He has 15+ years in healthcare, previously working at the U.S. Department of Health & Human Services, National Quality Forum, and the American Hospital Association.

Incentivizing high-quality care reduces costs while improving patient outcomes.

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Value-based care: Transforming Medicare for the better

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Smaller and medium-sized physicians’ practices and other medical service providers were 

The CEO of its corporate parent said he wants to help them stay afloat.

On May 1, UnitedHealth Group CEO Andrew Witty testified in the House of Representatives Energy & Commerce Committee Oversight and Investigations Subcommittee 

, "Examining the Change Healthcare Cyberattack." It was the second of his doubleheader of congressional testimony. Earlier in the day, he spoke about the Feb. 21 hack in a 

Based on more than two hours’ worth of questions from House Committee and Subcommittee members, it appears they, along with physicians and other health care providers, are suspicious about UnitedHealth Group’s connectivity and willingness to help.

UnitedHealth Group has invested about $300 million in cybersecurity, Witty said, and smaller and medium-sized health care businesses around the country have nowhere near that much to spend on it.

, call center at 1-866-262-5342, and interest-free, no-fee loan program meant to help physicians and other clinicians. The company has paid more than $6.5 billion in accelerated payments and the loans to about 142,000 tax identification numbers (TINs). An exact number of providers was not available because the number varies and they can move from TIN to TIN, but that does represent about one-third of all provider TINs associated with Change Healthcare before the attack, he said in questioning by Rep. Mariannette Miller-Meeks, MD (R-Iowa).

“So, very substantial uptake, very large fraction of those folks are small providers,” Witty said, with UnitedHealth Group “essentially auto-approving loans to small providers in matter of hours.”

That program remains open, and Witty acknowledged the company botched the first week or two of the loans. The lawmakers offered anecdotes of constituent physicians or other health care providers at first getting a few hundred or thousand dollars to sustain businesses that needed substantially more to maintain cash flow.

The company still is determining whose health or identifying information may be posted online. It may be up to one-third of the American population, Witty said. UnitedHealth Group will accept all responsibility for notifying people, he said.

A number of the lawmakers, including some of the physicians, asked about the cyberattack and hammered on the connections to continuing consolidation in health care.

Subcommittee Chair Rep. Morgan Griffith (R-Virginia) opened the hearing with that issue.

“How could something like this happen?” he said. “How did consolidation in the health insurance industry reach such a state that a single ransomware attack on one company can cripple the flow of payments and claims for months?”

“I firmly believe that consolidation in health care is not a good thing, OK?” said Rep. Larry Bucshon, MD (R-Indiana). “It's led to increased costs. We know that. Even though everybody says it will decrease costs, it does not.”

Rep. Kim Schrier, MD (D-Washington), said she was on the same wavelength as Bucshon regarding consolidation and its effects on patients and physicians.

“The reality is that this massive, far-reaching attack has disproportionately impacted small, independent practices that were already struggling to stay afloat and United's advanced payments have been appreciated, but insufficient, and other payers, as you've just heard, have done nothing to help. It is in their interest to hold on to that money,” she said. She offered the example of a small physical therapy practice in Washington where the owners had to mortgage their house to make rent and payroll, while UnitedHealth Group posted $371 billion in revenue in 2023.

Committee Chair Rep. Cathy McMorris Rodgers (R-Washington) called UnitedHealth the “poster child” of arrangements of insurers not trying to pay for patient care and maintaining ownership over doctors that are supposed to provide it. Rep. Buddy Carter (R-Georgia), a career pharmacist, displayed a literal poster that diagrammed UnitedHealth Group’s business interests sprawling across health care, and asked Witty about how his company can justify clear conflicts of interest.

“Thank you for the question and the challenge. I appreciate that,” Witty said. “We operate our organization with very clear firewalls between the organization and we are guided around a mission of trying to align incentives in the system to try and eliminate waste and abuse and to try and deliver value-based care to individuals. We know that when that happens, clinical outcomes improve and we believe the cost goes down for people involved in that process. That's what we focus on through the organization.”

UnitedHealth Group offered prior authorization flexibilities after the attack. Now physicians and other health care providers who took advantage of those now fear they could be subject to cumbersome audits or that UnitedHealth Group might second-guess some of the decisions users had to make while the systems were down, said Rep. Raul Ruiz, MD (D-California). He asked for assurance that UnitedHealth Group would not pursue unfair retroactive denials and clawbacks, and Witty agreed.

Rep. John Joyce, MD (R-Pennsylvania), asked why PA flexibilities for Medicare Advantage plans were not extended for other insurance, but Witty noted Medicaid decisions generally are left to states, and employers offering private insurance generally make their own rules regarding PA.

Rep. Kat Cammack (R-Florida) said providers who have taken loans to cover revenue shortfalls have said they felt pressured by UnitedHealth Group to make upbeat public statements about the support. Rather, Witty noted UnitedHealth Group staff asked providers who received loans to spread the word about the program, but upbeat public statements are not part of any approval criteria for the loans.

Apart from physicians, patients, pharmacists and other health-related effects, Rep. Michael Burgess, MD (R-Texas), encouraged Witty to continue working with law enforcement to find the culprits.

“I want to see someone arrested and marched into the center of town and shot for doing this,” Burgess said. Witty praised the efforts of the FBI and agreed with Burgess’ sentiment.

“I am completely aligned with you that I'd love to see these people brought to justice,” Witty said. “And I hope we're the last people they ever attack.”

Following testimony in Senate, UnitedHealth Group CEO Witty appears before House oversight subcommittee.

Reps question Change Healthcare CEO over cyberattack, hammer on effects of consolidation on smaller practices

Andrew Witty, CEO of Change Healthcare’s corporate parent, apologized to those affected by the massive cyberattack against the company that hobbled the U.S. health care system for weeks.

“To all those impacted, let me be very clear: I’m deeply, deeply sorry,” said Witty, CEO of UnitedHealth Group, based in Minnetonka, Minnesota.

Witty said he made the decision to pay a ransom to recover stolen data. Committee Chair Sen. Ron Wyden (D-Oregon) said the hack could have been stopped with “cybersecurity 101,” by using multifactor authentication (MFA).

Witty and Wyden spoke this morning in “Hacking America’s Health Care: Assessing the Change Healthcare Cyber Attack and What’s Next,” a 

 by the Senate Finance Committee. Witty is scheduled to testify this afternoon in a hearing on the same issue by the House of Representatives Energy and Commerce Committee.

Change Healthcare’s computer network largely is returning to normal, with core systems up and fully functional, Witty said. The company has “literally built this platform back from scratch,” so its system is safe for providers to reconnect to, he said.

Testimony begins in Senate Finance Committee.

Change Healthcare CEO Witty apologizes for effects of massive cyberattack

Andrew Witty, CEO of Change Healthcare’s corporate parent, apologized to those affected by the massive cyberattack against the company that has hobbled the U.S. health care system for months.

“Our response to this attack has been grounded in three principles: to secure the systems, to ensure patient access to care and medication, and to assist providers with their financial needs,” he said. “We have deployed the full resources of United Health Group in this effort. I want to assure the American public: We will not rest, I will not rest, until we fix this.”

Witty spoke May 1 to the Senate Finance Committee in the 

 “Hacking America’s Health Care: Assessing the Change Healthcare Cyber Attack and What’s Next.”

The lawmakers spent more than two hours pressing Witty on issues ranging from cybersecurity to UnitedHealth Group’s size and business practices, to the financial effects on doctors, hospitals and pharmacists, to the theft, potential revelation and misuse of huge amounts of patient information.

Committee Chair Sen. Ron Wyden (D-Oregon) repeatedly chastised Witty for the company’s response to a hack that could have been stopped with “

 (MFA). Witty admitted he is as disappointed and frustrated as anyone about the situation and the company did not get it right when rolling out 

 to physicians and other health care providers.

Witty said he made the decision to pay a $22 million ransom to recover stolen data, and it was one of the hardest decisions he ever had to make. So far, the company has not seen evidence that materials such as doctor’s charts or full medical histories were exfiltrated from its records. It will take months to identify affected patients and notify them, so UnitedHealth is offering two years of free credit monitoring and identity theft protection, he said.

For physicians and other providers, UnitedHealth has advanced more than $6.5 billion in accelerated payments and is offering no interest, no fee loans, Witty said. There is a 

 devoted to the incident and a call center open for inquiries at 1-866-262-5342.

Witty explained the cyberattack happened when hackers compromised a Change Healthcare server not protected by multifactor authentication, the technology that requires users to enter a password and an additional piece of information, such as a number, password, confirmation code sent via text, or fingerprint or facial scan, to log into a computer network.

“When your bank app asks you to enter a code sent by text or email, that's MFA. It secures your account even if your password is learned,” Wyden said.

The company requires MFA on externally facing computer systems, Witty said, and Wyden called it a security failure on Witty’s watch.

The reason the server did not have MFA is because Change Healthcare had only recently come under UnitedHealth Group and the company was in the process of upgrading Change Healthcare’s legacy computer systems, Witty said.

Once the hack happened, Witty said Change Healthcare disconnected from the rest of the health care system to stop additional cyberattacks and theft, and that worked.

Change Healthcare’s computer network largely is returning to normal, with core systems up and fully functional and safe for physicians, hospitals and pharmacies to reconnect with, Witty said.

“The reason why it's taken longer than you might expect to recover is, we've literally built this platform back from scratch, so that we can reassure people that there are not elements of the old attacked environment within the new technology, at the new technical environment that we created,” Witty said.

Sen. Thom Tillis (R-North Carolina) asked about the security and, once the attack happened, the redundancy of information to restore services quickly. Witty acknowledged the attack implicated the prime and backup data environments and delays happened partly due to the age of the technology and because large amounts of data were not secured in cloud data storage.

Tillis recounted his cybersecurity experience through the Senate Armed Services Committee and he held up a copy of the book “Hacking for Dummies.”

“And this is some basic stuff that was missed,” Tillis said. “So, shame on internal audit, external audit and your systems folks tasked with redundancy, they're not doing their job.”

“The other important point that you make, multifactor authentication is vital for prevention, but redundancy, which you touched on, basically helps the company get back on its feet. This company flunked both,” Wyden said.

Numerous senators shared anecdotes from their home states about patients, physicians, hospital leaders and pharmacists who all have spent months enduring the effects of the Change Healthcare cyberattack.

Committee Ranking Member Sen. Mike Crapo (R-Idaho) summarized the situation plainly.

“The fallout from this unprecedented attack has affected the entire health care sector,” Crapo said. “By crippling Change’s functionality, the hacker's left providers unable to verify patients insurance coverage, submit claims and receive payments, exchange clinical records, generate cost estimates and bills or process prior authorization requests. In the immediate aftermath of the attack. Many providers had to rely on reserves to cover the resulting revenue losses.”

The lawmakers noted the scale and size of UnitedHealth’s operations.

The company handles the equivalent of 5% of the U.S. gross domestic product a day, said Sen. Bill Cassidy, MD (R-Louisiana). The company has become “almost a too-big-to-fail insurer, because if it fails, it's going to bring down far more than it ordinarily would,” he said.

Witty countered that the company owns no hospitals or pharmaceutical makers. It employs about 10,000 physicians and contracts with another 80,000 who choose to work with UnitedHealth Group, while hospital employ about 400,000 physicians across the country.

Sen. Elizabeth Warren (D-Massachusetts) pounced, noting UnitedHealth reported $22 billion in profits last year, making it the largest health care entity in the nation, with the largest insurer, largest claims processor, largest controller of physicians, the largest participant in Medicare Advantage, and third largest pharmacy benefit manager. By revenue it is the 11th largest company in the world, she said.

“You are now in a position to jack up prices, squeeze competitors, hide revenues, and pressure doctors to put profits ahead of patients,” Warren said. “UnitedHealth is a monopoly on steroids. The opportunities for price gouging are everywhere.”

Federal regulators are investigating company’s billing practices and now it appears UnitedHealth is scooping up physician practices brought to the edge of bankruptcy by the company’s own data breach, Warren said. In questioning by Sen. Robert Menendez (D-New Jersey) Witty agreed to “commit to not exploiting the destabilized provider markets that you created to acquire other subsidiaries,” and Wyden later pressed Witty for assurances on that point.

Sen. Ron Johnson (R-Wisconsin) noted the United States government is the largest financial entity in the world with trillions in debt and that gets hacked and makes improper payments all the time.

CEO Witty apologizes for effects of the massive cyberattack, but Senate Finance Committee chair says the company ‘let the country down.’

Alan Berkenwald, MD

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